Kiowa County Sheriff’s Office
Kiowa County Sheriff’s Office
1305 Goff St. PO Box 427. Eads CO 81036
Application for Employment
Patrol Deputy
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Personal History Statement
You are being asked to provide information about yourself that will be used in an investigation to evaluate your suitability for employment with the Kiowa County Sheriff’s Office. The information for the background investigation includes information collected from you, criminal records, drivers history, questionnaires and personal interviews.
Print or write legibly in black ink in your own hand writing. Do not type on this form or have another person make entries for you.
All information requested must be supplied and is subject to verification.
Deliberate inaccuracies, omissions, or incomplete statements will remove you from the employment process.
If a question does not apply, please enter “N/A” in the space provided. If more space is required, please attach additional 8 ½ x 11 sheets of paper as necessary.
It is your responsibility to make sure that all information is accurate.
It is to your advantage to answer all questions truthfully and completely. Any negative factors in your application will be evaluated in terms of the circumstances and the facts surrounding the event. Honesty and Integrity are key factors in the employment selection process.
You will be required to submit the following with your application:
o Copy of Birth Certificate
o High School Diploma, GED or transcripts
o College or University Transcripts (unofficial copies are acceptable)
o Original copy DD214
o Copy of POST Certification (if applicable)
You may be required to submit:
o Copy of marriage certificate or divorce decree
o A resume
The contents of this packet will be considered confidential and will only be used for investigating employment suitability with the Kiowa County Sheriffs Office.
There is one exception to the confidentiality of your background investigation. Should it be discovered that you are currently, or have been involved in criminal activity; the law enforcement agency with jurisdiction will be notified.
Please complete the following application in BLACK ink only. Make sure all hand writing is legible, accurate, and complete.
NAME:
(please print) Last First M.I.
Address:
Street Apt City State ZIP Code
Date Of Birth: Phone:
Month/Day/Year
SSN: License Number: State:
Related Experience: In order to be eligible for testing for PATROL DEPUTY you must meet one of the following:
I am Currently Colorado POST certified:
PID Number
I am certified in another state:
State PID Number
I am Currently enrolled at:
Academy Graduation Date
Education: The Commission of Peace Officers Standard and Training require a peace officer to posses a High School Diploma or GED equivalency. Please use additional pages if necessary.
High School Attended: Date Graduated:
Name Mo/Year
College or University: Date Attended:
Name Mo/Year to Mo/Year
Course of study or Degree: Credits:
College or University: Date Attended:
Name Mo/Year to Mo/Year
Course of study or Degree: Credits:
College or University: Date Attended:
Name Mo/Year to Mo/Year
Course of study or Degree: Credits:
Military: All male U.S. citizens, and male immigrants living in the U.S., who are 18 through 25, are required to register with Selective Service.
Selective Service Number:
Have you ever served as a member of the armed forces? Yes No
Branch: Dates of Service:
Discharge Date: Discharge Status:
Please include a copy of your DD214
Family Information:
Current and Former Spouses:
|Last |First |Middle |Date Of Birth |
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Children: Please list all children and step-children whether living with you or not.
|Last |First |Middle |Date Of Birth |
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Residence Information: Beginning with your current address and working back please list all residences you have lived in the last ten years. Please include military bases (if applicable).
|From |To |Street Address |City |State |Zip Code |
|(mo/yr) |(mo/yr) |Apt # | | | |
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Please list any individuals, except spouses or parents, that have lived with you since the age of 18.
|Last |First |Phone Number |Date of Birth |
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Employment History: Please list any law enforcement agency that you have applied with within the last ten years.
|Date |Agency |Steps of Application taken (written, psychological, |Contact or |
| | |Background, physical agility, Oral interview, ect.) |Investigator |
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Beginning with the most recent, working backwards, please list all jobs, including part time, temporary and volunteer positions you have held within the last ten years. Please account for any military service, school, or unemployment.
|From: (mo/yr) |To: (mo/yr) |Company: |
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|Phone: |Supervisor: |Address: |
|Job Title: |Salary: |May we Contact: (if no please explain) |
|Duties: |
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|Reason for Leaving: |
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|From: (mo/yr) |To: (mo/yr) |Company: |
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|Phone: |Supervisor: |Address: |
|Job Title: |Salary: |May we Contact: (if no please explain) |
|Duties: |
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|Reason for Leaving: |
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|From: (mo/yr) |To: (mo/yr) |Company: |
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|Phone: |Supervisor: |Address: |
|Job Title: |Salary: |May we Contact: (if no please explain) |
|Duties: |
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|Reason for Leaving: |
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|From: (mo/yr) |To: (mo/yr) |Company: |
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|Phone: |Supervisor: |Address: |
|Job Title: |Salary: |May we Contact: (if no please explain) |
|Duties: |
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|Reason for Leaving: |
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|From: (mo/yr) |To: (mo/yr) |Company: |
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|Phone: |Supervisor: |Address: |
|Job Title: |Salary: |May we Contact: (if no please explain) |
|Duties: |
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|Reason for Leaving: |
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|From: (mo/yr) |To: (mo/yr) |Company: |
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|Phone: |Supervisor: |Address: |
|Job Title: |Salary: |May we Contact: (if no please explain) |
|Duties: |
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|Reason for Leaving: |
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|From: (mo/yr) |To: (mo/yr) |Company: |
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|Phone: |Supervisor: |Address: |
|Job Title: |Salary: |May we Contact: (if no please explain) |
|Duties: |
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|Reason for Leaving: |
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Driver License History:
Do you posses a valid Colorado Drivers License? Yes No
If yes: Number Class Expiration
Please list any other state you have held a Drivers License.
|Name (last, first, MI) |State |Number |Dates (mo/yr-mo/yr) |
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Has your license ever been revoked, suspended or denied? Yes No
If yes, please explain.
________________________________________________________________________________________________________________________________________________________________________
Have you been charged with a DUI/DUID in the last five years? Yes No
If yes, what was the final disposition? ____________________________________________________
Please list any traffic citations or accidents you have had in the last five years.
|Date |Agency/Location |Charge |Disposition |
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Criminal History: Have you ever, as an adult or a juvenile, been arrested, taken into custody, or been issued a misdemeanor citation?
|Date |Agency/Location |Charge |Disposition |
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Please list any other crimes you have committed, regardless of whether or not you were stopped, arrested and or convicted. Include what, when, why and how.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Drug History:
Have you ever used the following, and if so what was the last date used:
Yes No Date last used Number of times
|Marijuana | | | | |
|Cocaine | | | | |
|Heroin | | | | |
|Methamphetamine | | | | |
|Tranquilizers | | | | |
|Hallucinogens | | | | |
|MDMA (Ecstasy) | | | | |
|Inhalants | | | | |
|Prescription Medication | | | | |
(NOT Prescribed to you or NOT as directed)
References: Please provide a minimum of three references who would be able to comment on your character, experience, personality, and qualifications relevant to this job. These references should NOT include current or previous supervisors or employers, relatives, significant others or their relatives.
|Name: |Phone: |
|Address: |Email: |
|Name: |Phone: |
|Address: |Email: |
|Name: |Phone: |
|Address: |Email: |
|Name: |Phone: |
|Address: |Email: |
|Name: |Phone: |
|Address: |Email: |
|Name: |Phone: |
|Address: |Email: |
In your own words, please explain why you want to work in the field of law enforcement, specifically why you wish to work for the Kiowa County Sheriffs Office.
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Thank you for your interest in the Kiowa County Sheriffs Office.
Release of Information Agreement
Kiowa County Sheriffs Office
Name:_________________________________ Date of Birth:_____________
Address:____________________________________________________________
____________________________________________________________
SSN:__________________ License #:__________________ State:____________
To Whom it May Concern:
I am an applicant for a position with the Kiowa County Sheriffs Office. The agency needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I have applied. It is in the public’s best interest that all relevant information concerning my employment and personal history be disclosed to the above agency.
I hereby authorize any representative of the Kiowa County Sheriffs Office bearing this release to obtain any information in your files pertaining to my employment records, excluding medical records. I hereby direct you to release such information upon request of the bearer. I do hereby authorize a review and full disclosure of all records, or any part thereof, concerning myself by and to any duly authorized agent of the Kiowa County Sheriffs Office, whether such records are public, private, or confidential in nature. The intent of this authorization is to provide pertinent information to the Kiowa County Sheriffs Office to consider in the determining my suitability for employment with that Agency. It is my Specific intent to provide access to personnel information, however personal or confidential it may appear to be.
I consent to the release of any and all public and private information that you have concerning me. This includes but is not limited to the following: employment records; personal background and reputation information; military service record; educational records; financial status and records; criminal history records to include all arrest records and any information contained in the investigatory files; efficiency and performance ratings; complaints and grievances filed by or against me; records or recollections of attorneys at law or other counsel whether representing me or another person in any case, either criminal or civil; attendance records; polygraph examinations and results thereof; any internal affairs investigations and/or disciplinary actions taken against me, including any files which have been deemed to be confidential or sealed.
I hereby release you, your organization, and all others from liability or damages that may result from releasing or furnishing information requested, including any liability or damage pursuant to any State or Federal laws. I hereby release you, as custodian of such records, and all other officers, employees, or related personnel, both individually and collectively, from any and all liability and damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. I direct you to release such information upon request of the duly accredited representative of the Kiowa County Sheriffs Office regardless of any agreement I may have previously made with you to the contrary. The Kiowa County Sheriffs Office, requesting the information pursuant to this release will discontinue pursuing my application if you refuse to disclose the information requested.
For and in consideration of the Kiowa County Sheriffs Office acceptance and processing of my application for employment, I agree to hold officers, its agents and employees harmless of any and all claims and liability associated with my application or in any way connected with the decision of whether or not to employ me with the Kiowa County Sheriffs Office. I understand that should information of a serious criminal nature become know as a result of this investigation, such information may be turned over to the proper authorities.
I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, the Colorado Revised Statues 24-72-201 and 24-72-301, the Colorado Open Records Act; and my rights under any other State Records Act, with regard to access and disclosure records, and I waive those rights with the understanding that the information furnished will be used by the Kiowa County Sheriffs Office in conjunction with employment procedures.
A photocopy or FAX of this release waiver will be valid as an original thereof, even though said photocopy or FAX copy does not contain an original writing of my signature.
This waiver is valid for six months (180 days) from the notarized date of my signature.
Should there be any questions to the validity of this release, you may contact me at the address listed on this document.
I agree to indemnify and hold harmless the person to whom this request is presented, their agents and employees, from and against all claims, damages, losses and expenses including reasonable attorney’s fees arising out of or by any reason of complying with this request.
|Name (print) |Subscribed and sworn before me this day of |
|Signature: |Notary Public |
|Date: |My commission expires: |
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